Subject: [omrc-eb] Medical Survey Information Results
From: Jerry Heilman <jerry@kristinandjerry.name>
Date: 3/1/2012 11:36 AM
To: OMRC Board <omrc-eb@engr.orst.edu>
CC: Matt Crawford <pdn362@gmail.com>, Chris Davis <davisc20@gmail.com>

Medical Survey Information Results Howdy All,

Thanks a lot of gathering and sharing this information.  I do not know about the rest of you, but I know the CMRU executive board REALLY likes the increased sharing of information that has been happening the last year or so.  It is really nice to have feed back from peers when looking at complex issues like this one.

Here are all of the replies from everyone.

Team Name:  CMRU

(1) What are the minimum medical requirements for your team members?  Minimum of some form of wilderness or BLS certification such as: WFR, OEC, First Responder, EMT-B (or higher).

(2) Does your team have a supervising physician that sponsors your medical protocols?  Yes

(3) If "yes" to #2, is the physician provided through the county that you work with or does he/she volunteer their services to your team independent of the county?  He is an associate member of the unit, not provided by the county.

(4) What is your physician's specialty and paid position?  General Practice (DO), and EMS volunteer doctor for Dallas volunteer fire department.
 
(5) Does your team support "wilderness protocols" (e.g. WFR)?  If so, what unique wilderness protocols are supported? Yes, dislocation reduction, epi in back country for anaphylaxis, BLS airway management in back country.
 
(6) If "yes" to above, do you have a supervising physician that has signed off on the wilderness protocols?  Yes
 
(7) Does your team/doctor support protocols for state licensed EMTs (e.g. EMT-basic, paramedic, etc)?  Yes

(8) Do your medical protocols support medications?  If so, what medications and for what conditions?  Yes: epi/benedryl for anaphylaxis, oxygen.  See the attached PDF document "CMRU First Responder Protocols.pdf" for protocol details.

(9) What other information regarding your medical protocols and/or supervising physician may be unique and worth noting? N/A
 
(10) What challenges (current and future) do you see in supporting medical protocols for mountain rescue teams?  Finding supervising docs qualified to support changing state EMS requirements.


 
Team Name:  DCMRU

(1) What are the minimum medical requirements for your team members?  The minimum requirements for Deschutes County Sheriff's Search and Rescue as a whole is Wilderness First-aid.  Members must maintain this level of training or higher to remain an active member.

(2) Does your team have a supervising physician that sponsors your medical protocols?  Yes, our supervising physician is an ER Doctor at St. Charles Medical Center.

(3) If "yes" to #2, is the physician provided through the county that you work with or does he/she volunteer their services to your team independent of the county?  Our supervising physician volunteers his time and is independent of the county.

(4) What is your physician's specialty and paid position?  Emergency Department Physician St. Charles Medical Center.

(5) Does your team support "wilderness protocols" (e.g. WFR)?  If so, what unique wilderness protocols are supported?  Our team supports wilderness protocols, primarily focusing on environmental and prolonged evacuation aspects of the protocols.

(6) If "yes" to above, do you have a supervising physician that has signed off on the wilderness protocols?  Yes, we worked with our supervising physician to develop all wilderness protocols.  These protocols are blended with our regional EMS protocols.

(7) Does your team/doctor support protocols for state licensed EMTs (e.g. EMT-basic, paramedic, etc)?  Yes, in Bend we operate under the same (but modified to contain wilderness) protocols as local fire departments.  Deschutes County SAR participates in the maintenance and development of protocols by attending the ECEMS (East Cascade EMS) group meetings.

(8) Do your medical protocols support medications?  If so, what medications and for what conditions?  Yes, we maintain most BLS medications i.e Epi, Asprin, Albuterol, and Nitro.  Our unit also has few ALS medicines like Morphine, Benedryl,Zofran, and I.V solutions.  We do not have cardiac monitor so we do not work under ACLS protocols.  Our use of Morphine is primarily for pain relief due to injury.

(9) What other information regarding your medical protocols and/or supervising physician may be unique and worth noting?  Mainly that we only have an AED, therefore, our Paramedics and RN's do not operate using ACLS protocols.

(10) What challenges (current and future) do you see in supporting medical protocols for mountain rescue teams?  I don't really know of any challenges we face here.  We are comfortable working with what we are given. Our main challenge is using the medications before they expire.  There is alot of money wasted on expiring medications.



Team Name: Hood River Crag Rats

(1) What are the minimum medical requirements for your team members?  CPR Card (AHA or ARC)

(2) Does your team have a supervising physician that sponsors your medical protocols?  Christopher Van Tilburg, MD

(3) If "yes" to #2, is the physician provided through the county that you work with or does he/she volunteer their services to your team independent of the county?  Volunteer medical advisor and volunteer MRA Medcom member but not independent of county since all deployments are authorized by SO.

(4) What is your physician's specialty and paid position?  Wilderness, travel, emergency medicine (FAWM, CTH, ATLS); Providence Hood River Occupational and Travel Medicine and Providence Hood River Mountain Emergency Services (Mt. Hood Meadows)

(5) Does your team support "wilderness protocols" (e.g. WFR)?  If so, what unique wilderness protocols are supported?  No, we are BLS unit only.

(6) If "yes" to above, do you have a supervising physician that has signed off on the wilderness protocols?  N/A

(7) Does your team/doctor support protocols for state licensed EMTs (e.g. EMT-basic, paramedic, etc)?  No.  Only if EMT requests to be officially (simultaneously) deployed by EMS system (not SAR system) or if ski patrollers (OEC) are on duty at the ski resort involved in a mission.  Otherwise we do not support EMS protocols for state licensed providers.

(8) Do your medical protocols support medications?  If so, what medications and for what conditions?  No protocols, so no meds.  See #7, if a SAR member requests to be deployed as EMS member, they fall under county protocols and county EMS medical director (Dick Virk MD, also a member of Hood River Crag Rats).  Some members (EMS, MD, RN) carry their own personal medications.  If they dispense to a third party, probably would fall under Good Samaritan law (at least for physicians).  But this is not official policy or protocol

(9) What other information regarding your medical protocols and/or supervising physician may be unique and worth noting?  N/A

(10) What challenges (current and future) do you see in supporting medical protocols for mountain rescue teams?  We are barely able to keep people CPR certified.  We have not enough rescues to keep skills up, despite whatever training (WFR, CPR, OEC, rope rescue) members possess.  WFR is not a licensed position or certification and some things taught in WFR may be unlawful to attempt by an unlicensed provider.



Team Name:  Eugene Mountain Rescue

(1) What are the minimum medical requirements for your team members?  Basic First Aid and CPR for all members, and WFA or higher for support and rescue level.

(2) Does your team have a supervising physician that sponsors your medical protocols?  Yes.

(3) If "yes" to #2, is the physician provided through the county that you work with or does he/she volunteer their services to your team
independent of the county?  Provided by Lane County Sheriff's Office.

(4) What is your physician's specialty and paid position?  ER MD.

(5) Does your team support "wilderness protocols" (e.g. WFR)?  If so, what unique wilderness protocols are supported?  Not for First Aid, WFA, WFR, etc.  The baseline skills taught are their treatment standard.

(6) If "yes" to above, do you have a supervising physician that has signed off on the wilderness protocols?  N/A

(7) Does your team/doctor support protocols for state licensed EMTs (e.g. EMT-basic, paramedic, etc)?  Yes for EMT-B, -I, and -P..

(8) Do your medical protocols support medications?  If so, what medications and for what conditions?  Yes.  Medical and trauma.

(9) What other information regarding your medical protocols and/or supervising physician may be unique and worth noting?  Provide for long-term care.

(10) What challenges (current and future) do you see in supporting medical protocols for mountain rescue teams?  N/A



Team Name:  Portland Mountain Rescue

(1) What are the minimum medical requirements for your team members?  CPR and first aid, although we strongly recommend that all members become WFR’s.  PMR will subsidize members to take an outside WFR class for initial certification.  We then put on a recert class every two years using an professional instructor.  We have moved away from having our members become state certified unless they are already certified because of their employment because of the difficulties surrounding this.

(2) Does your team have a supervising physician that sponsors your medical protocols?  Yes

(3) If "yes" to #2, is the physician provided through the county that you work with or does he/she volunteer their services to your team independent of the county?  Our physician advisor is an associate member of our unit.  Most of the actual work is done by our medical committee which is composed of field members who are both medical professionals or interested WFR’s.

(4) What is your physician's specialty and paid position?  Emergency physician

(5) Does your team support "wilderness protocols" (e.g. WFR)?  If so, what unique wilderness protocols are supported?  Yes.  We have “guidelines” for our wilderness providers who are not state certified.  Here is the text from  our document describing those:

Specific guidelines:

-Airways: Wilderness providers may not use invasive airways including oropharyngeal or nasopharyngeal airways.

-Bleeding: Bleeding should be treated with direct pressure.  Life-threatening bleeding not stopping with direct pressure may be treated with a tourniquet applied just above the injury, although this is rarely necessary.  If the tourniquet is applied after a complete amputation, it should be left in place.  If not the limb is not amputated, the tourniquet should be loosened every 30 minutes to assess whether it is still necessary for bleeding control. [1]

-Defibrillation: Any provider may use an automated external defibrillator (AED): turn on the unit and follow the directions.

-Selective Spinal Immobilization:  Any patient with a potential mechanism of injury for spinal injury or complaint of neck pain should have a focused spinal assessment by a provider trained to do so.  If the patient has a potential mechanism for spinal injury or neck pain and no provider is present to assess the spine, the patient should be placed in full spinal immobilization.  In cases of extreme danger to patient and rescuer (e.g. active rockfall), the risks versus benefits of moving the patient without optimal assessment or immobilization must be weighed by the most qualified person available.  See the medical chapter of the PMR training manual for our preferred methods of spinal immobilization.

    -Perform a separate spinal assessment after completing the primary and secondary surveys
    -The procedure described here is different from that for state-certified medics.
    -The patient may be cleared from spinal immobilization if ALL of the following are present:
        -Fully awake and alert, with normal mental status
        -No alcohol or medications that might alter his or her level of consciousness.
        -No distracting injuries.
        -Normal movement and feeling in arms and legs.
        -No pain or tenderness when pushing on the bones of the entire spine.
        -No pain with neck movement. [2]

-Medications: Wilderness providers trained to do so may administer epinephrine by auto-injector for anaphylaxis or oxygen.  No other drugs may be administered, including over the counter drugs. Providing sugary food, liquids, or oral glucose for suspected hypoglycemia is allowed by any provider.

-Extremity injuries:  Extremity injuries should be splinted in a normal anatomic position.  Axial (in-line) traction may be applied to return a deformed extremity to the anatomical position.  More vigorous attempts to reduce a suspected dislocation should not be attempted unless the extremity has no pulse or feeling.

-Wound Care:  Most clean wounds can simply be bandaged if expected transport time is short.  Consider irrigating wounds with clean water if dirty or if evacuation will be delayed.  Wounds should not be closed with sutures, glue, or steri-strips.

-Hypoglycemia:  All providers may give oral glucose or sugary foods for suspected hypoglycemia.  This would almost always occur in the case of a diabetic patient who took insulin or oral diabetes medicines and then did not eat or overexerted him or herself.  Glucose or dextrose (in some packaged cake frostings) are the agents of choice and can be rubbed on the gums of a semi-conscious patient.  The amount of carbohydrates in a tube of glucose (96 calories in a 31 gram tube) is inadequate to prevent the blood sugar from dropping again, and should be followed by a more substantial meal if the patient improves with the smaller dose and has no contraindication to eating.

-Hypothermia: [3],[4]

    -Mild hypothermia:  (alert, vigorous shivering, good vital signs).  If patient is otherwise healthy and shivering well, he/she should be:
        -DRY (remove any wet layers)
        -INSULATED (i.e. clothes, sleeping bag, blanket or hypowrap)
        -FED (high-calorie food/drink, if patient is not at risk of choking)
        -OBSERVED (45-60 minutes, unless immediate threats present)
        -WALKED OUT (carefully, if physical/mental status gets worse with exercise, STOP immediately & reinsulate the patient)

The purpose of rewarming the patient for 45-60 minutes in a hypowrap before walking them out is to decrease core temperature afterdrop and to mitigate the poor judgment and lack of dexterity that might lead to a further injury.

    -Moderate / Severe Hypothermia:  (altered mental status/unconscious, decreased/absent shivering, decreased/absent vital signs)
        -Keep these patients lying flat and move them carefully.
        -Gently place the patient in an insulated “hypo-wrap.”
        -Carefully check vital signs over 60 seconds.
        -Evacuate the patient ASAP to an advanced medical facility for rewarming.
        -Do NOT attempt aggressive rewarming in the field.
        -Heating blankets may be placed on the torso but should not touch bare skin.
        -Do NOT give fluids/food to patient with altered mental status
        -Do NOT rub extremities (no frictional heat, only skin/tissue damage).

In severely hypothermic patients with NO DETECTABLE PULSE (as assessed over 60 seconds by the clock), clinical decisions should be based on ability to transport and transport time:

-If transport time out of the field will be less than 3 hours, begin rescue breathing, protect patient from further heat loss and DO NOT start chest compressions. While rescue breathing using a Bag-Valve-Mask, aim for a respiratory rate of 6 breaths/minute.  If using Mouth-to-Mask, give 12 breaths/minute. Carefully transport the patient to definitive medical care.  Performing chest compressions while transporting a patient in a litter is not effective.

-If transport time out of the field will be more than 3 hours, begin rescue breathing. Continue rescue breathing for 3 minutes (by the clock) as improved oxygenation may improve cardiac function and make it detectable.  If patient still does not have a pulse (as assessed over 60 seconds by the clock), start chest compressions and continue for up to

(6) If "yes" to above, do you have a supervising physician that has signed off on the wilderness protocols?  Yes

(7) Does your team/doctor support protocols for state licensed EMTs (e.g. EMT-basic, paramedic, etc)?  We defer to the local Multnomah/Clackamas/Washington county protocols available on the Multnomah County Website at http://web.multco.us/health/emergency-medical-services.  We did not feel that we could easily extent the scope of practice for these providers, so state certified EMT’s actually have a MORE restricted scope of practice than our non-state-certified wilderness providers.  A number of years ago, we wrote our own version of the local protocols, which are signed off on by our physician advisor.  However, these are somewhat out of date, so we plan to scrap them and just approve the county protocols.

(8) Do your medical protocols support medications?  If so, what medications and for what conditions?  Yes, see #5.  However, we do not stock any of these medications, so epinephrine for anaphylaxis would be given only if a member, subject, or bystander happened to have it.

(9) What other information regarding your medical protocols and/or supervising physician may be unique and worth noting?  N/A

(10) What challenges (current and future) do you see in supporting medical protocols for mountain rescue teams?  State EMS, which is designed for fire and ambulance services is a poor fit for the infrequent call volumes and austere conditions of volunteer mountain rescue.

[1] Doyle GS, Taillac PP. Tourniquets: A Review of Current Use with Proposals for Expanded Prehospital Use. Prehospital Emergency Care, 2008; 12(2): 241-256.

[2] Reworded from Forgey WW.  Practice Guidelines for Wilderness Emergency Care, Second Edition. Wilderness Medical Society, 2001.  Globe Pequot Press, Guilford, CT.

[3] Wilderness Medical Society Practice Guidelines, 2006.

[4] State of Alaska Cold Injuries Guidelines, 2003.